What I know, what I don't know and what happens in between

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Bring out the scapegoat

It has been quite the week here in paradise. I really need to work on developing the aresolized ativan room spray – although what I would really like is some sort of spray that increases the self-awareness of the HUA syndrome.

Healthcare is always an interesting field to observe, for it is made up of people. People at their absolute best, people at their absolute worst and all shades in between. Tying those people together in a sticky web is the culture of the place, which can and often does mires us in immobility and a sense of victimhood.

I’ve thought quite a bit this week about Kimberly Hiatt, the nurse from Seattle who killed herself following the tragic medication error where she administered too much Calcium Chloride to her patient, an infant in the NICU. So many things are disturbing about this event and yes, it is awful and should not have happened that the child died, but the aftermath of that event provides us a very good window into seeing how it could have happened.

A google search of the news around these deaths will bring up headlines proclaiming that Kimberly ‘killed’ the patient, or made a ‘blunder’. Words are important and this type os sensationalized creates an impression she was intentional, even when the word accidental is inserted, or careless when she blundered. One report tells of the hospital being found blameless yet Kimberly was still under investigation when she took her own life. Yet, how can the hospital be found blameless while the nurse’s investigation was still underway. They are tied together unless the belief is that she intentionally overdosed the child. The hospital fired her following this event, which implies she was at fault, and fault implies that she could have done differently. She was then painted from that moment onwards as the nurse who made a careless blunder and killed a child, was fired from her career and under investigation. Since the hospital was blameless, it must have been her fault, and fault is what our society so dearly looks for.

This fault find, searching for a scapegoat culture in an industry that is so complex, creates a further layer of fear and mistrust where what is needed most is trust.

When I needed to arrange an interview this week between two nurses and the consultant from patient safety department who was doing a review of an event that occurred a week previously in our unit, the first thing the nurse who had been in charge ask was if she needed to bring in someone with her like her union representative. I carefully explained that the interview was not about finding out WHO was at fault, but rather about finding out HOW this happened and how could it be prevented from happening again. In a culture where you can be fired when an error happens you sense distrust that you can come forward and acknowledge and error made.

Another event shone a light on the complexity of the system when the discovery was made that using the Lifescan glucometer in an environment that had been cleaned with a hydrogen peroxide cleaner could result in false high readings. In the investigation into this it was discovered that someone somewhere in the organization had knowledge about this several months ago, but how did the information not get shared? Just exactly who do you talk to when you need to get such information out to such a wide group in a rapid time to prevent potential injury and error? No one seems to know and no one seems to be willing to take the step of making a wide sweeping recommendation about what to do. And so, another week will go by where the information remains held by a few. Communication is so very important but so very few of us do it well.

And deep inside this complex culture an experience nurse complains about trivial things – ‘Who is supposed to clean the mouse?’, ‘Why does the pyxis machine take so long to open?’, ‘the keyboard tray drops down too far!”, all indications of victimhood, deeply held belief that someone else is responsible and the completion of a workplace hazard identification rather than the self-awareness of individual responsibility.

In another place deep inside the complexity another nurse administers a potentially life altering medication. She was interrupted 5 times in the mixing and administering of that medication which was ordered by a physician and verified by the nurse as the correct drug because it was not legible, while the physician was accessing his iphone at the same time as talking to her, and obtained from the pyxis machine that dispensed the medication from the drawer which had been filled 2 hours earlier by a pharmacy technician who was new to the job, and decided upon by the care team based on information provided by the patient that he had only an allergy to some antibiotic, I think it was penicillin.

I wonder how many times I administered a medication that harmed a patient that I never even knew about.

Go safely about your business, there is nothing to see here. Move along.